Head and Neck Pathol (2012) 6:369372

DOI 10.1007/s12105-012-0359-2

SINE QUA NON RADIOLOGY-PATHOLOGY

Paranasal Sinus Mucocele

Gregory G. Capra Peter N. Carbone
David P. Mullin

Received: 13 April 2012 / Accepted: 28 April 2012 / Published online: 24 May 2012
Springer Science+Business Media, LLC (Outside the USA) 2012

Abstract Paranasal sinus mucoceles are epithelium-lined

cystic masses usually resulting from obstruction of sinus
ostia. They most frequently occur in the frontal and ethmoid sinuses. While ophthalmologic symptoms are most
common, patients also report rhinological or neurological
complaints. The close proximity of paranasal sinus mucoceles to the orbit and skull base predisposes the patient to
significant morbidity. Computed tomography displays a
non-enhancing homogenous mass with expansion of bony
walls. Magnetic resonance imaging reveals variable
intensity of T1-weighted images and a hyperintense mass
on T2-weighted images. Histopathologically mucoceles
have features of respiratory mucosa with areas of reactive
bone formation, hemorrhage, fibrosis, and granulation tissue. Surgical excision is the standard treatment with trends
towards endoscopic techniques.
Keywords Paranasal sinus mucocele
Magnetic
resonance
Computed tomography
Blindness

Ophthalmologic
Optic neuropathy
Cranial neuropathy

Osteolysis
Inflammatory infiltrate

The opinions and assertions expressed herein are those of the author
and are not to be construed as official or representing the views of the
Department of the Navy or the Department of Defense.
G. G. Capra (&)
D. P. Mullin
Department of Otolaryngology, Naval Medical Center San
Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-5000,
USA
e-mail: gregory.capra@med.navy.mil
P. N. Carbone
Department of Anatomic Pathology, Naval Medical Center San
Diego, San Diego, CA, USA

History
A 54-year-old female with a history of cataracts was
referred by an ophthalmologist to the Otolaryngology
Clinic for acute worsening of visual acuity and diplopia in
the right eye. Symptoms began 5 months prior and were
described as a white curtain in her vision. Her ophthalmologic exam showed proptosis and chemosis of the eye
and her visual acuity ipsilaterally was 20/100 (baseline
20/25). The optic disc was pink and healthy on exam.
Cranial nerves III, IV, V, and VI were intact, with only
minimal impairment of extraocular muscle movement.
Radiographic Features
A non-contrast computerized tomographic (CT) scan of the
head and orbits showed a 4.4 cm 9 4.2 cm 9 3.3 cm
well-circumscribed expansile mass in the right ethmoid
sinus. The medial orbital wall was expanded with evidence
of mass effect upon the medial rectus muscle and optic
nerve (Fig. 1). Nuclear magnetic resonance images (MRI)
of the head with and without contrast demonstrated a
hyperintense mass on T2-weighted images (WI) and a
hypointensity on T1WI. The MR fluid attenuation inversion recovery (FLAIR) sequence suggested proteinaceous
fluid (Fig. 2).
Treatment
The mass was emergently decompressed through an
endoscopic approach in the operating room. Resistance to
retropulsion of the right eye resolved immediately and the
patients visual acuity returned to baseline within 24-h of
surgery.

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Fig. 1 Axial images of CT scan of orbits with contrast demonstrating

a 4.4 9 4.2 9 3.3 cm mass consistent with a right ethmoid mucocele.
The medial orbital wall has expanded and mass effect on the medial
rectus and optic nerve is noted. Right-sided proptosis is also present

Diagnosis
Histological examination of a hematoxylin and eosin
stained slide demonstrated benign respiratory mucosa with
mild chronic inflammatory infiltrate and areas of reactive
bone (Figs. 3, 4).

Discussion
Paranasal sinus mucoceles are epithelium-lined cystic
masses, are mucus filled, and result from obstruction of
sinus ostia. Mucus accumulation causes enlargement of the
mass with associated sinus bony wall expansion that is

Head and Neck Pathol (2012) 6:369372

considered to be sine qua non for this entity. Prostaglandins

and collagenases aid in osteolysis and further enhance the
expansile nature of the cysts [13]. Except in the case of
pyeloceles, they are generally benign and slow growing
with the potential, through mass effect, to cause local
morbidity upon neighboring structures [1, 4, 5].
Paranasal sinus mucoceles most commonly occur in the
third or fourth decades of life with a slight male predilection [3, 5]. The frontal sinus is most commonly affected
followed by the ethmoid sinuses, with reports suggesting
7090 % of mucoceles occur in these locations. Ten percent of mucoceles occur in the maxillary sinus and the
sphenoid sinus is involved rarely [36]. The general
mechanisms of cyst formation are inflammation, trauma, or
tumor distortion of sinus outflow tracts. In addition to
inflammatory obstruction of ostia, primary causes also
include cystic dilation of mucosal glands or polyp degeneration. Secondary causes most commonly result from
previous sinus surgery or facial trauma. Other predisposing
factors include cranial dysplasias, chronic sinusitis, and
sinonasal manifestations of systemic disease [3, 4, 7]. In
cystic fibrosis, 16 % of patients with chronic rhinosinusits
also have mucoceles [3].
Symptoms vary depending on the location of the
mucocele and may be classified as rhinological, neurologic,
or most frequently ophthalmologic [5, 7]. In general,
fronto-ethmoidal involvement causes mass effect upon the
orbit leading to proptosis, hypophthalmos, diplopia, and
periorbital swelling. Conversely, visual compromise is
more common with posterior ethmoid and sphenoid mucoceles because the thin walled lamina papyracea may be
displaced into the optic canal by an expanding mucocele.
Optic neuropathy may ensue from direct mechanical
compression, ischemia, or optic neuritis secondary to
inflammation. Other structures that may be involved

Fig. 2 Axial MR imaging of the brain with T1WI (a), T2WI (b), and contrast-enhanced T1WI (c) demonstrating an ethmoid mucocele causing
mass effect on optic nerve and medial rectus

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Fig. 3 Hematoxylin and eosin stain of ethmoid mucocele lined with

ciliated pseudostratified respiratory-type epithelium with acute and
chronic inflammatory infiltrates and fibrosis

include the third, fourth, fifth, and sixth cranial nerves and,
rarely, the pituitary. Sphenoidal mucoceles are also more
commonly associated with headaches [1, 7, 8].
Radiographically, CT scans provide basic anatomical
detail of the mucocele, delineate its interaction with
neighboring bony structures, and aid in surgical planning.
CT scan findings show an expansile, homogenous sinus
mass that is not rim-enhancing, unless associated with an
acute mucopylocele. Bony destruction is not common but
expansion and remodeling of bone is seen in association
with the mucocele [2, 4]. MRI is superior in identifying the
relationship of the mucocele to neighboring soft tissue and
in distinguishing from other soft tissue neoplasms. Signal
intensity of T1WI and T2WI is dependent upon the viscosity and fluid content of the cyst [5]. On T2WI, mucoceles are hyperintense owing to their high water content.
With time, the intensity may diminish due to chronic inspissations. In contrast, T1WIs have low signal intensity
initially but, with water absorption and increased protein
concentration over time, a more viscous mucocele changes
from an isointense to hyperintense structure [4].
Histologically, mucoceles within the paranasal sinus
have features of respiratory mucosa with cyst walls demonstrating single-layered, pseudostratified, ciliated,
columnar epithelium [2, 3, 8]. Although metaplastic
changes are rare, chronic cases will show evidence of
squamous metaplasia. Reactive bone formation is also
possible in areas adjacent to cyst epithelium [2]. Mucoceles
show elevated expression of IL-12, which secondarily
leads to increased expression of IL-2 and interferon
gamma. Subsequently, an increased activation of TH2
lymphocytes hastens the presence of a chronic inflammatory infiltrate [3]. Additional findings include cholesterol

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Fig. 4 Hematoxylin and eosin stain demonstrating osseous erosion

associated with the ethmoid mucocele

granuloma, hemorrhage, fibrosis, and granulation tissue.

Central nervous tissue may also be identified in those cases
of intracranial herniation [2].
Surgical excision is the treatment of choice and early
intervention is indicated to prevent visual compromise or in
cases of pyelocele [1, 7]. Historically, mucoceles have been
removed through external approaches, such as a LynchHowarth incision, Caldwell-Luc approach, or an osteoplastic
flap. Recent trends have moved toward endoscopic management, when appropriate, and this has shown improved
morbidity and recurrence rates [5, 7]. Overall recurrence
rates vary among sources, but it is considered to be less than
10% of reported cases [3, 5]. Optic neuropathy is the greatest
concern and visual outcomes are generally good. Poorer
outcomes are related to posterior ethmoid and sphenoidal
mucoceles or delayed treatment of pyeloceles [1, 7].
Acknowledgments The authors would like to thank Dr. Brenda
Nelson for her support and advice with writing this paper.

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